Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Tuesday, April 21, 2009

One way to derail a promising medical career . . .

is to serially rob prostitutes at gunpoint and occasionally murder them. While BU Medical School has not hesitated to suspend Mr. Markoff, and will no doubt expel him should he be convicted of felony murder, short of such extreme circumstances, medical schools and residency programs are often disconcertingly reluctant or ineffective when it comes to purging incompetent, bizarre and even dangerously psychopathic individuals from the profession. Don't get me wrong -- these cases are uncommon, and aren't reflective of the medical profession per se. But the fecklessness of institutions in dealing with these rare serious wackos does point to more widespread, though less profound problems with the assurance of medical professionalism.

One of the most notorious cases is that of Michael Swango, a serial murderer of patients who also enjoyed poisoning his colleagues with arsenic-laced doughnuts. In spite of these bad habits, he managed to maintain a career in medicine for 13 years, bumping off an estimated 60 people. As Bill Vourvoulias writes in reviewing James B. Stewart's book on the case, Blind Eye:

Swango's poisonous ways began at the Ohio State University Hospitals in Columbus. Three witnesses saw the young intern inject a substance into a patient's IV moments before she suffered a life-threatening seizure. Swango gave conflicting accounts of the incident, but the senior doctor assigned to investigate took his word over that of the witnesses (none of whom were doctors), and the hospital dropped the matter.After completing his internship, Swango spent the summer of 1984 in Quincy working at an EMF unit, where he often bought doughnuts and drinks for his co-workers. When a number of paramedics came down with violent flu-like symptoms, they had a glass of iced tea tested; it contained arsenic. The evidence was strong enough to convict Swango of battery.

After his release from jail in August 1987, his life became curiously repetitive: He'd secure a residency by falsifying records; mysterious deaths that were circumstantially traceable to him would follow; hospital officials would become concerned but do little; they'd learn about his past, usually through the media, and revoke his privileges; and Swango would find another hospital willing to hire him.

Actually, one might ask why Swango was admitted to the OSU residency program in the first place. As a medical student at Southern Illinois University, Swango was fired from his moonlighting job as an ambulance driver for forcing a heart attack victim to drive himself to the hospital. His fellow students were so disturbed by his bizarre behavior and evident incompetence that they wrote to officials about him. A vote to expel him fell just short.

In 1991, Berkshire Medical Center employed a second year resident whose first year had been oddly divided between two institutions, but he came with references. According to an account of the case in Academic Medicine (Tulgan, et al, Nov. 2001):

From the very onset of employment, unusual behavior was observed. Textbook publishers were approached for complimentary books on the basis of a nonexistent medical school faculty rank. Offers to teach nurses, for a fee, were made. Behavior in the hospital food line was inappropriate. The resident had difficulty in organizing ward rounds and in interacting with fellow residents and medical students. When approached with suggestions, there was inability to admit to faults or to take corrective action. Attending physicians were dissatisfied about patient care and professional deportment.

The resident claimed that both peers and attending physicians were subversive. Allusions were made to a conspiracy. A physician from the second prior institution was accused of having passed $3,000 to two members of this staff to make the BMC experience unworkable for the resident. Age discrimination was also raised, although a number of peers were older. After five months of continued inability to resolve these numerous problems, corrective action as defined in the Residency Program Personnel Policies of BMC was implemented.

snip

It has been a matter of concern throughout the process at BMC that neither program director at the other institutions conveyed any warning about potential problems. Indeed, one hospital actually misled us. Honest communication between programs should be encouraged and could ward off situations such as ours and the others we have cited.

As it turns out, this dismissed resident then embarked on a 9 year course of litigation which was very costly to BMC. No doubt the other institutions feared such consequences, as did the institutions through which Michael Swango passed. More generally, physicians who are only marginally competent or who behave inappropriately with patients are commonly sent off with positive recommendations. Rather than leaving the profession or ending up in roles without patient contact, they may simply fall down the ladder and end up as prison doctors or in other settings where employers are not very concerned about patient welfare. (Yes, that's a sweeping assertion -- I believe I can back it up but I don't have time today.)

Again, all the physicians I know are exemplary professionals who are dedicated to their patients. This is an institutional problem which many are concerned to solve, not an indictment of medicine. Still, no good can come of ignoring it.